Stroke research in HSR&D

June 2016

According to the Centers for Disease Control and Prevention, each year more than 795,000 Americans have a stroke — and one out of every 20 deaths in the United States is caused by stroke1. Among U.S. Veterans, approximately 15,000 suffer a stroke each year2.

About Strokes

Strokes involve problems with the blood supply to the brain, and fall into two major categories — ischemic and hemorrhagic.

Ischemic strokes occur when an artery supplying blood to the brain becomes blocked, cutting off the oxygen supply to nearby brain tissue. In ischemic strokes, the blockage is most often caused by a blood clot3. It's estimated that almost 85 percent of strokes are ischemic.4 Among U.S. Veterans, approximately 6,000 hospital admissions each year are attributable to ischemic strokes.5

Hemorrhagic strokes occur when an artery in the brain leaks blood or ruptures. The leaking blood puts pressure on brain tissue, causing damage.

In addition to ischemic and hemorrhagic strokes, transient ischemic attacks (TIA) — also known as "mini-strokes" — can impede blood flow to brain tissue. In a TIA, blood flow to the brain is blocked only for a short time; however, a TIA is a warning sign of future stroke and should be treated as a medical emergency, like a major stroke. 6

Strokes can have serious health consequences for both survivors and their loved ones. Those who survive a stroke may be left with functional disabilities ranging from partial paralysis to loss of speech, vision, or hearing7. Friends or family of a stroke survivor may take on the role of informal caregivers — something that can have a major impact on an individual's life8.

Stroke Risk Factors and VA Research

While anyone, at any age, can have a stroke, increasing age is considered the single most important risk factor for stroke. Additional risk factors include9:

High blood pressure,

Heart disease,

Diabetes,

Cigarette smoking, and

Prior stroke.

As the Veteran population ages — the average women Veteran is 49, and the average male veteran is 6410 — research into stroke prevention, and post-stroke care and rehabilitation, is critical. Studies funded by VA's Health Services Research & Development Service (HSR&D) address many aspects of care for Veterans either at risk-for, or recovering from stroke including: Support for caregivers of Veterans recovering from stroke; quality of care for Veterans with stroke, and long-term care quality for post-stroke rehabilitation. The following are just a few of the completed and ongoing HSR&D-funded studies on stroke research.

Using Stories to address disparities in Hypertension
Hypertension (HTN) is chronic condition, which, if left uncontrolled, may lead to stroke, organ damage, or cardiovascular disease. It disproportionately affects African-Americans, and despite improvements in hypertension (HTN) control among VA patients, disparities remain — particularly for minority Veterans. Few efforts to improve HTN control have focused on culturally-sensitive interventions. In this recently completed study, investigators used a culturally-focused, narrative intervention (personal stories) designed to improve HTN control among African-American Veterans using VA care.

In Phase 1 of the study, investigators developed the intervention: a DVD of African-American VA patients with HTN telling their personal stories about how they came to control their high blood pressure. In Phase 2 of the study, investigators compared this intervention to the control — a non-story-based, educational DVD. Study participants were sent a "booster" DVD at three months to view at home. The "booster" DVD was either the control or intervention, and included content similar to the initial DVD. Survey and blood pressure (BP) data were collected at baseline and six months.

Investigators recruited 620 African-American Veterans, and completed follow-up for 534 of those patients. Participants were randomized to either the stories (intervention) group or the educational DVD (control). After watching the intervention DVD, Veterans reported the content was more emotionally engaging (mean=4.3 on 7-point Likert scale) compared to control (mean= 3.2). At follow-up, 87% intervention strongly agreed/agreed that they were confident they could maintain lifestyle change, compared with 77% controls. Looking at physiologic outcomes, at baseline, the mean systolic blood pressure was 138.4mmHg with no significant difference by group. At follow-up, there was a 3.3mmHg difference in blood pressure, favoring the intervention. Participants also reported significantly greater intentions to change several behaviors related to hypertension management including: becoming more physically active; using salt substitutes; talking openly with their doctor about hypertension, and remembering to take hypertension medication.

Impact: In an at-risk population of African-American Veterans, adding personal stories of Veterans resulted in increased emotional engagement and downstream positive effects on self-reported behavior and objectively measured BP.

Utilizing the RESCUE Stroke Caregiver Website to Enhance Discharge Planning
For informal caregivers of Veterans who have had a stroke, depression is common. Further, caregiver depression has been shown to be a major contributor to the stroke survivor's readmission to the hospital or to a long-term care facility. Research has indicated that helping caregivers resolve problems is effective in reducing depressive symptoms; however, many problem-solving interventions are not widely used because they involve multiple in-person or telephone-based sessions.

This is a multi-site (Gainesville, Tampa, Miami), ongoing, four-year study. Investigators are using a randomized controlled trial to test a problem-solving intervention for stroke caregivers that involves web-based education on the RESCUE stroke caregiver website, as well as skills training. The intervention is delivered during one post-discharge telephone session, followed by in-home sessions delivered online via a messaging center. Investigators hypothesize that stroke caregivers who receive the intervention will have fewer symptoms of depression compared to stroke caregivers in usual care. The study will also look at the effect of the intervention on stroke caregivers' knowledge, sense of burden around their caregiving role, perceptions about positive aspects of caregiving, self-efficacy, and health-related quality of life. Investigators also plan to look at:

Effect of the intervention on Veterans' outcomes (i.e., functional abilities and healthcare utilization),

Budgetary impact for implementing the intervention, and

Barriers, facilitators, and best practices for implementing the intervention

Impact: This research has the potential to improve the quality of and access to post-stroke, transition-to-home care for Veterans and their caregivers. Investigators expect to update the currently available VA RESCUE stroke caregiver website and produce an evidence-based model (post-discharge support and training delivered over the phone and online) that can be applied to other conditions.

Principal Investigator: Constance R. Uphold, PhD, ARNP, FAAN is Associate Director of Implementation and Outcomes Research with the VA Geriatric Research Education and Clinical Center (GRECC), and is part of HSR&D's Center of Innovation on Disability and Rehabilitation Research (CINDRR) in North Florida, South Georgia, and Tampa.

VA Post-Stroke Rehabilitation: Comparing Institutional Long-Term Care Settings
Effective post-stroke rehabilitation can speed patient recovery and minimize stroke-related functional disabilities. Within VA, community living centers (CLCs) and VA-contracted community nursing homes (CNHs) are the two major sources of institutional long-term care for those Veterans with stroke who receive VA care. In this recently completed study, investigators sought to compare the quality and regional variations of rehabilitation therapy and restorative nursing care among Veterans residing in VA CLCs versus that of Veterans in VA-contracted CNHs. The study compared national and regional differences between CLCs and CNHs in:

Using observational data that included all Veterans diagnosed with stroke and admitted to CLCs or VA-contracted CNHs from January 1, 2006 through December 31, 2009, investigators identified 18,272 Veterans (69% from CLCs and 31% from CNHs) diagnosed with stroke at 2,479 nursing homes (5% for CLCs and 95% for CNHs). Results indicated that the CLCs differed significantly from the CNHs: CLCs had higher rates for urban and hospital-based facilities, fewer average beds, and lower resident/beds ratio. Compared with their counterparts at the CNHs, Veterans at the CLCs were more likely to be younger, male, less educated, black, separated or divorced, urban residents with high VA healthcare priority, and to have more comorbid conditions. Compared with their counterparts at CNHs, Veterans at CLCs had fewer average rehabilitation and depression care days, but they were significantly more likely to receive restorative nursing care.

Impact: Given the incidence of stroke among the Veteran population, it's expected that study findings will help inform VA policymakers, clinicians, and Veterans across a spectrum of decision-making processes, including: placement options for Veterans, policy decisions around post-stroke institutional long-term care, and clinical quality improvement efforts.

1 CDC Website and CDC, NCHS. Underlying Cause of Death 1999-2013 on CDC WONDER Online Database, released 2015. Data are from the Multiple Cause of Death Files, 1999-2013, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program. Accessed Feb. 3, 2015.